Provider Demographics
NPI:1356537443
Name:ROSS VAN ANTWERP DO MPH PA LASER CENTER OF MARYLAND
Entity type:Organization
Organization Name:ROSS VAN ANTWERP DO MPH PA LASER CENTER OF MARYLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:VANANTWERP
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:410-544-4600
Mailing Address - Street 1:484 RITCHIE HWY STE A
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-2961
Mailing Address - Country:US
Mailing Address - Phone:410-544-4600
Mailing Address - Fax:410-544-0997
Practice Address - Street 1:484 RITCHIE HWY STE A
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-2911
Practice Address - Country:US
Practice Address - Phone:410-544-4600
Practice Address - Fax:410-544-0997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0033830261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD8581RJOtherGRP
MD8581Medicare PIN